That Universal Healthcare is Superior to Multi-Payer Healthcare

The question on tap today is whether Universal Healthcare is superior to Multi-Payer Healthcare. When it comes to healthcare, there are only two important metrics:

1) The Financial Metric, or what it costs each person to receive adequate healthcare.

2) The Quality Metric, or what the outcome of receiving healthcare is.

These are actually rather challenging to quantify, but Pro will do our best to prove that Universal Healthcare excels at both of these beyond Multi-Payer.

Healthcare is remarkably expensive under multi-payer systems. In the US, one of the only modernized countries in the world to use a multi-payer system, medical spending per person in 2018 reached USD$11,172 per person, or USD$3.6 trillion total. This money isn't divided among all persons evenly, of course; some shouldered much larger financial burdens than others¹.

A study at John Hopkins University found that "Single-payer systems usually have an advantage
over multi-payer systems in the efficiency of
collecting revenues, overall cost control, and the
capacity to subsidize health care for low-income
individuals²."

National health expenditures further show the cost of multi-payer. An analysis of the data available finds that other countries spend half as much per citizen on healthcare as the US does³.

There are a large number of sources that corroborate this data, but in summary, the cost per person for adequate healthcare is lower under a universal/single-payer system than it is under a multi-payer system.

The quality of care is harder to put into numbers than the financial side of healthcare. However, there is a great deal of data suggesting that outcomes between multi-payer and universal systems are extremely similar in many ways, with the exception of one piece of data which Pro will discuss momentarily.

For some data we will turn again to Peterson-KFF's analysis of the data⁴. The analyses included here find the following:

- The mortality rate in the US and other wealthy countries has fallen in tandem.

- The US has a poorer rate of Amenable Mortality (the rate at which people die to diseases preventable by adequate healthcare).

- The US has a much worse Years of Life Lost rate than other countries (though it continues to fall in both cases).

- Disease Burden is worse in the US than other countries.

- People us the hospital more in the US than in other countries.

- The US has a higher rate of medical and lab errors than other countries.

- Adults in other wealthy countries have quicker access to doctors and nurses.

Also, remember that predictor mentioned earlier? The one piece of data that predicts better healthcare outcomes in the US is income. Data from a Texas A&M study revealed "Perhaps not surprisingly, babies born to wealthier and better educated parents in the United States tended to fare about as well as infants born in European countries. On the other hand, those babies born to mothers in the United States without these advantages were more likely to die than any other group, even similarly disadvantaged populations in the other countries⁵." So, if you have less money, your access to healthcare is diminished, a problem in both quantitative categories.

The one wealthy country using a multi-payer healthcare system has poorer outcomes and more expensive care than those using a universal system based on an enormous amount of data.

Pro thanks the judges and looks forward to Con's response.

1) https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical

2) https://web.pdx.edu/~nwallace/GHS/SingleMultiHI.pdf

3) https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends

4) https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-amenable-mortality-measured-by-healthcare-access-and-quality-index-2016

5) https://www.sciencedaily.com/releases/2016/10/161013103132.htm

My position in this debate is that I, a relatively healthy individual who spends a lot of time, effort and money to stay healthy, should not have to subsidize the frequent hospital visits of many of my peers who are more careless with their health. While the burden of proof rests with my opponent, I intend to both answer his case and briefly explain my counter-model. First, though, let me address why I win this debate on principle.

Typically, people who affirm this topic argue that healthcare is a human right. Pro, however, has entirely failed to establish that having better healthcare is a good thing for people. The problem with this argument is that because healthcare cannot be (usually) freely provided, every major country has established that labeling healthcare as a human right creates a significant free-rider problem. This is why nations, at their best, only provide healthcare for their own citizens or in their own regions. As a result, no country on Earth has truly universal healthcare. They only have nationalized healthcare.

Pro's arguments don't work on a universal scale. All his points implicitly assume the existence of a plurality of healthcare systems. His statistics all refer to what happens in just one nation. On a universal scale, healthcare would be virtually impossible to co-ordinate even if my opponent did support it, given how difficult it is for doctors to even get on the ground in places like Palestine or Yemen while it is being attacked. Coordinating it would require a one world government, or at least, a global ministry of health. Even the World Health Organisation doesn't have nearly that kind of power.

Politicians have spun the term universal healthcare because it sounds cool. It doesn't really mean coverage throughout the universe, and I think that's a problem. Pro has established, through the sources he has selected, a specific form of coverage that he wants to defend, known as "single payer." In this system, which he failed to explain, everyone pays money to the government (usually via taxes, although pro doesn't specify) and then the government pays doctors, nurses, lobbyists, bureaucrats, researchers, politicians etc. There are normally some exclusions, like cosmetic surgery, although pro hasn't mentioned any so I assume in his preferred system I won't get spam emails about enhancement pills anymore. The government will have already paid for them. It's worth noting that the more lobbying influence there is of pharmaceutical companies on the government in a single-payer system, the greater the degree of corruption preventing normal people from getting coverage while lining the pockets of the political elite. Given how corrupt US healthcare is already, it's interesting that my opponent chose this country as his setting, when he could have chosen to set this debate in any country including those where so-called "universal healthcare" is already working fine. I applaud him for his bravery in defending the merits of corruption.

I think (for the purposes of this debate, anyway!) a more reasonable concept of healthcare than all of the above is that nobody is entitled to it. Modern healthcare systems are a privilege based on the hard work of numerous doctors who deserve compensation for their expertise, much like any other transaction. I also categorically deny that keeping all people alive for a lower cost is a good outcome. Unhealthy people should die young as a natural consequence of their actions. Examples include heavy smokers, addicts, obese people, and many more. This all ties in to my overall principle of fairness. Fairness is more important than health because with fairness, you get a more balanced society with more self-responsibility. With health, you get a lethargic society full of corruption and misery. Of course, pro makes no attempt to prove healthy is always good. If he did want to defend that, he might as well get the guts to defend truly universal healthcare. As an additional benefit, although by no means important to my case, this also deals with human overpopulation by killing off the dumb.

Even assuming that you disagree with the above analysis, I do not think pro has demonstrated these benefits well.

Pro's only study that attempted to explain why costs would go down under a single-payer system (which he labelled as coming from John Hopkins University) compared types of health insurance. This is confusing because insurance usually covers specific types of healthcare (in New Zealand, for example, though as the study notes "A challenge for this type of system is to limit the
degree to which the supplementary private system
detracts from the public system" which proves that the public system can often not compete). In fact the study terms this a problem with multi-payer systems in the form of risk selection, meaning people with poor health will just get the types of healthcare that covers their needs. I think that's actually a plus, because it means I don't have to pay for the needs of people with poor health care, and those people will not need to pay for things that are unlikely to affect them (if they DON'T buy insurance, which the study doesn't even consider, then the insurance companies don't need to profit and doctors can get all that sweet cash directly). To counteract adverse selection, unhealthy people will be driven to bankruptcy by insurance companies, which again, I think is a good thing; to quote: "Sicker individuals are
more likely to want to buy health insurance and
health insurers cannot afford to insure only
unhealthy people." So the authors correctly conclude that in multi-payer systems it's more likely that your premiums go up as you get more likely to become sick.

Overall, the study did not find single-payer health insurance systems (and remember, this is health insurance as opposed to healthcare) were superior, despite what pro seemed to think at a cursory glance. It explicitly holds up the example of the Czech Republic doing better under multi-payer, and concludes: "Single-payer and multi-payer systems each have advantages which may meet countries’ priorities for
their health insurance system." There are other points to be made here, but my opponent spent, like, zero effort on this other than a brief quote, so I want to see what he picks up.

The true reason why costs are so high in the US has little to do with it being universal or multi-payer, although some bureaucracy and corruption may shift around. The blue cross identifies three key factors of high healthcare costs in the US - note blue links in this paragraph are clickable and take you to informative infographics with sources. First (of no particular order) there is the cost of chronic diseases, chiefly obesity, cancer and heart disease. All of these are strongly linked to the second, which is that many people in the US have poor lifestyles, especially consuming alcohol and tobacco, and eating fatty foods. The third, currently much smaller (but, crucially, getting worse) factor, is the high cost of prescription drugs (personally, I would add over-medication of prescription drugs because of pharmaceutical lobbying). These causes support my position of paying drug researchers and doctors, not drug companies and insurance bureaucrats, which I will examine below.

I think there is a significant negative effect on health quality when it is not made clear to people that taking up smoking = signing your death warrant. Rather than aggressively fighting poor lifestyle habits, most countries today (but the US in particular) are aggressively legalizing even more proven ways to get sick, such as smoking marijuana for "recreation." Pro broadly agrees that universal healthcare is not higher quality, and I agree the quality is roughly the same, all else being equal. Therefore pro has not demonstrated a benefit in this category, and has not proven his burden.

He did show babies sometimes die younger when parents are poorer in the USA. Two responses. First, this is one correlation. Babies also die younger if exposed to second-hand smoke. Second, this problem could be solved 

Fine. :(

But then you're still going to be paying more in a system that doesn't actually give you better coverage. It just means more people are sick because the system is well-equipped to keep them alive despite their poor choices. In this model, quality and cost of care are no longer your important metrics, but something more like life expectancy. I await pro defending living a long, miserable existence :)

Let's get rid of all the smoke for a second. How about - when you're sick, you pay to get better? No need for complicated taxes or single-payer health insurance. 

If we want to determine who we fund and how we fund them for healthcare, we currently already do that on websites like give-a-little when people cannot afford it.

To disincentivise rich people from making poor lifestyle choices, denying access to otherwise healthy people of modest means, hospitals should be required to levy an additional tax on wealthy people with poor lifestyles, which subsidizes drug research. And to stop hospitals price gouging, there's a number of options such as a maximum price (which would get regularly adjusted to ensure doctors and nurses are fairly compensated).

Finally, just because healthcare is typically best when it's multi-payer, doesn't mean single-buyer drug systems don't work. They clearly do. Government buys all the drugs, and therefore drug companies cannot keep gouging the price. Simple, and many countries already do this.

The resolution is negated.

It seems that Con has decided they'd like us all to chase a Red Herring, so let me quickly quash that.

The common vernacular of Universal Healthcare is accepted to mean nationalized single-payer, and I'm frankly uninterested in defending a system that neither myself nor anyone else is discussing or in favor of, so let's drop this now, shall we?

I'm going to jump between arguments a bit, so bear with me as we go.

Con has done a lovely job defining single-payer healthcare and the definition provided will brook no argument from Pro. However, they've taken several curious lines of defense, as follows:

1) The Amoral Argument, effectively arguing that equality of access to and quality of care is an unfair burden - numbers with no morality. Theoretically, there's nothing wrong with this approach on paper, but Con has now raised a point that Pro thinks they must defend: Sick people deserve to die if they cannot afford their own care. Pro would also like to point out that many people with physical ailments contribute greatly to society when given access to care. If these people were unable to get this care because of a cost, the human race would be damaged as a whole.

2) You pay more for the same care! Apparently Con has decided to ignore the fundamental argument of Round 1. Your care is at least as good under single-payer as it is under multi-payer. Similarly, many examples were given in which the US - the largest country on Earth to continue to use a multi-payer system - fails compared to other countries, while the cost burden averages much higher than in other countries. Finally...

I want to draw special attention to this point because it appears to be the crux of my opponent's argument. My opponent's only statistic to back this claim is one of high drug prices in the US - Pro agrees, and I'll go so far as to say that it doesn't stop at drugs. All types of medical care in the US are higher, and often exceptionally so, than in other countries. Con has decided to dig their own grave with this information, because the reason prices are so much higher is due to the multi-payer system in place. Private insurance demands discounts on healthcare services and products, so the industry increases prices in response, and the cycle continues. Multi-payer systems are controlled by capital and the market, and prone to corruption, and Con has admitted such and tried to use it as a leg up against single-payer systems; I wonder if the judges will be as perplexed as I was on reading that. A research article in HealthAffairs sums this up¹: "As private third-party payers consolidated in the early 1990s and their
market clout grew, they moved away from negotiating with hospitals based
on charges and toward contracts based on lower fee schedules or
negotiated rates... Hospitals responded by marking up billed charges
even faster than the costs of care for such patients." Private insurance is driven by multi-payer care, and in turn drives the corruption that my opponent seems so offended by and opposed to. Single-payer eliminates the opportunity for this problem.

While I think the arguments from the first round haven't been reasonably disproven or negated, I have more to add.

Countries with single-payer healthcare have better access to regular doctor visits. This was briefly mentioned in the last round, but let's talk about what it actually means. People with a regularly visited doctor are able to get checkups and health advice for maintaining good health. Smoking, drinking, and other types of recreational drug use are discouraged by doctors. But if you have to go to the hospital when you need care, and you only go in an emergency, you don't have a healthcare authority giving you guidance on a regular basis. This is not only a noteworthy point in Pro's favor, but further refutes Con's point about the use of the US healthcare system as an example.

The resolution is validated, and the negation is refuted.

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1) https://www.healthaffairs.org/doi/full/10.1377/hlthaff.25.1.45

The resolution is negated.

Con is right in their claim that the US has a higher rate of chronic disease and risky lifestyle behaviors, but their interpretation is that this is a problem that cannot be helped by universal care. A common thread on every study that has been done on the matter of chronic disease in wealthy countries is that all other countries included had universal care. Some examples are here, there, etc. The correlation is staggering and feeds into supporting the resolution, regardless of any gymnastic thought processes my opponent would like to use. As a quick aside, the analysis of data used in Round 1 showed that quick access to a doctor is better in countries with universal care than in the US, another point that my opponent has decided to skip over.

I'd like to now address the question of the Pharmaceutical industry. As Con pointed out (and Pro agrees with this statement), "Big Pharma," as Con calls it, has a stranglehold on the healthcare industry in the United States. The fact that it is an industry is one of the problems, but this angle was already discussed, so we'll go a bit deeper here. We don't have to look far; the study used in the first round, now cited by both my opponent and myself, included the idea that universal systems allow for better price control on prescription drugs and other forms of care - this was in the quote provided. Perhaps Con missed this?

Con has decided to have a fight about what constitutes fairness in healthcare. Multi-payer systems unfairly favor those with additional resources (capital), regardless of their level of health. All I really have to say about this comes out of arguments from the first two rounds, which can be summarized with the idea that people deserve care regardless of access to capital or status. That defines fairness in the eyes of Pro, and leads us to Con's argument...

Con's goal at this point appears to be redefining my points to suit their wishes, and at this point has become completely unresponsive to the arguments set forth in Round 1. The judgement of the power of a healthcare system still comes down to the two ideas presented there: Quality and Cost. Con knows that Multi-Payer has no advantages in either, and even admitted such. My opponent made the statement:

"I'd preferin principle (even if it was more expensive or meant everyone got marginally worse care) to prioritize those who rarely need to go to hospital."

My opponent thinks the best possible healthcare system would be one where sick people get worse care or no care, while we prioritize the people who need care the least. Again, a fascinating statement when their entire argument sits on the knife point of what is and is not fair. If I were taking my opponent's side, I'd want to avoid mentioning either the Soviets or the Nazis, Con has shown a worrying approval for allowing the deaths of people based on economic status, intelligence, disability, etc. I sincerely hope that my opponent is being hyperbolic, because if not, they've taken a morally repugnant stance on the subject.

Con has failed to refute the arguments made, and instead has attempted to redefine my arguments and twist data like a chunk of silly putty. My original two points stand backed by mountains of studies and data, and one needn't look far to understand this. My opponent's one argumentative pillar, the idea of fairness, has been soundly refuted (even if they say it hasn't). The head-scratching attempts to defend a system that restricts healthcare to rich, healthy people is baseless and completely backwards, especially when combined with an insistence that it is fairer than a system that gives all people, regardless of resources, access to care.

The resolution is validated, the negation is refuted.

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1) https://www.ncbi.nlm.nih.gov/books/NBK154469/

2) https://www.healthaffairs.org/doi/full/10.1377/hlthaff.26.6.w678

3) https://www.hcfama.org/blog/startling-results-us-vs-european-rates-chronic-disease

I thank my opponent for a fun debate. In this last round I'll just offer a few short closing reflections.